Effective September 19, 2026
Effective for dates of service on and after September 19, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiology. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by section
Imaging of the Brain
- Expanded indications for computed tomography (CT) cerebral perfusion
Imaging of the Extremities
- Allowances management without requiring repeat x-ray for osteomyelitis, avascular necrosis
- Specification for triangular fibrocartilage complex instability bypassing requirement for conservative management
- Meniscal tear knee: Added allowances following meniscal repair
- Knee arthroplasty pre-surgical imaging: Expanded allowance when conventional arthroplasty not feasible; specification of deformity criteria
Imaging of the Spine
- Modality specifications for spinal infection and axial spondyloarthropathy
- Spine pain/radiculopathy: Condensed content, added frequency limitation
Nuclear Medicine Imaging
- Condensed content for osseous tumors and established malignancy/neoplasm
- Added content for radioembolization scintigraphy using non-liver specific CPT codes
Vascular Imaging
- Separated content into 2 guidelines: Advanced Imaging for Vascular Indications and Vascular Ultrasound and Physiologic Testing
Advanced Imaging for Vascular Indications
- General
- Added indication for positron emission tomography (PET)/CT for vasculitis
- Brain, Head and Neck
- Added allowances for newly added computed tomographic angiography (CTA) Head/Neck code for aneurysm, arteriovenous malformation, dissection, fibromuscular dysplasia, pulsatile tinnitus, procedure related imaging, stenosis or occlusion, and
signs/symptoms/abnormal imaging
- Duplex ultrasound required prior to CTA/ magnetic resonance angiography (MRA) for all signs or symptoms of stroke/transient ischemic attack that have been present more than 30 days
- Removed allowance for advanced vascular imaging for syncope to align with professional society guidelines
- Added criterion for CTA/MRA for evidence of stroke on brain imaging
- Added criterion for CTA/MRA for evaluation of subclavian steal syndrome
- Chest
- Added surveillance intervals following endovascular repair for thoracic aortic dissection
- Added criteria for surveillance after repair of thoracic aortic aneurysm
- Abdomen and Pelvis
- Reduced required number of antihypertensive medications from 4 to 3 for renal artery stenosis to treat refractory hypertension to align with the European Society for Vascular Surgery guideline recommendations
- Added surveillance indication after endovascular revascularization of the aortoiliac vessels
- Added criterion for imaging of pelvic venous disease
- Upper Extremity
- Modified post-revascularization imaging intervals in upper extremity peripheral arterial disease to align with lower extremity criteria
- Lower Extremity
- Aligned the post-revascularization intervals for surgical and endovascular revascularization in peripheral arterial disease
Imaging of the Heart
- Cardiac CT with Quantitative Evaluation of Coronary Calcification
- When coronary artery calcium is used for go/no go statin decision and score is zero, recommend repeat study in 5-10 years to reevaluate statin question (provided other criteria still met)
- Magnetic resonance imaging (MRI) Cardiac
- Expansion of criteria for when to allow cardiac MRI for hypertrophic and non-compaction cardiomyopathy
- PET Myocardial Imaging
- Clarification of language in indications for PET Perfusion Imaging
Effective for dates of service on and after September 19, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Sleep Disorder Management. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Polysomnography
- Removed respiratory disturbance event definition
- Clarified suspected sleep disorder other than obstructed sleep apnea
- Added criteria to align with best practices for established sleep disorder (obstructed sleep apnea or other) – follow-up laboratory studies
- Added criteria for nocturnal seizures for In-lab (attended) sleep studies in non-adult patients (age 17 years or younger)
Bi-Level Positive Airway Pressure Devices
- Aligned criteria with recently published American Academy of Sleep Medicine updated clinical practice guideline for treatment of central sleep apnea - Journal of Clinical Sleep Medicine. 2025.
Effective for dates of service on and after September 19, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Genetic Testing. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
All Genetic Testing guidelines
- General Requirements:
- Added statement that testing be performed in a Clinical Laboratory Improvement Amendments certified lab accredited by the College of American Pathologists
Carrier Screening in the Reproductive Setting
- Clarified screening limited to once per lifetime for a given gene instead of for a given condition
- Removed exclusion (clarification): molecular screening for conditions where nonmolecular techniques can be used
Prenatal Screening using Cell-free DNA
- Added medically necessary indications for fetal red blood cell antigen screening using cell-free deoxyribonucleic acid (cfDNA)
- Clarified scenarios on use of cfDNA screening considered not medically necessary, including removal of Rhesus D antigen and/or other fetal red blood cell antigens
Genetic Testing for Inherited Conditions
- General Requirements:
- Clarified that germline genetic testing is limited to once per lifetime for a given gene except when individual is inadequately tested
- Allowed testing for an inherited condition per member health plan drug-specific policy requirements
- Clarified that multigene panel testing is considered not medically necessary when either whole exome or whole genome sequencing is being or has been performed
- Cardiac conditions:
- Hereditary arrhythmia syndromes: clarifications
- Hereditary cardiomyopathy syndromes: removed age restriction in symptomatic individuals and allow for genetic testing of either symptomatic or presymptomatic individuals with a family history
- Hereditary aortopathies: clarifications
- Primary mitochondrial diseases: targeted gene panel expanded from <25 to <30 genes
- Thrombophilia testing:
- Added two criteria for individuals with a venous thromboembolism (VTE): Pregnancy or postpartum up to 6 weeks, or estrogen exposure
- Added a criterion for individuals with or without a VTE and low activated protein C resistance activity
- Edited one criterion for individuals without a VTE contemplating pregnancy and first-degree relative with VTE and high-risk thrombophilia
- Added criteria for individuals without a VTE: Pregnant or postpartum and a first-degree relative with a history of VTE and high-risk thrombophilia or cancer receiving chemotherapy at low or intermediate risk of thrombosis and a first-degree
relative with a history of VTE
- Clarified scenarios considered not medically necessary
- Biomarker testing for rejection in solid organ transplantation
- For individuals ≥15 years of age post-cardiac transplantation: Testing is allowed beginning at 2 months post-transplant (reduced from 6 months), with testing frequency permitted at 2-month intervals (reduced from 3 months) between
2 and 12 months after transplant.
- Clarified additional scenarios and related tests for gene expression profiling, donor-derived cell-free DNA (dd-cfDNA), and MicroRNA testing considered not medically necessary
For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. You can also access and download a copy of the current and upcoming guidelines.
Effective September 4, 2026
Negative Pressure Wound Therapy (NPWT) Devices in Adults, 1.01.508 PBC | Premera HMO
Title Change
- Title changed from Negative Pressure Wound Therapy (NPWT) Devices in Adults to Negative Pressure Wound Therapy (NPWT) Devices.
Medical necessity criteria updated
- Eliminated the age restriction limiting the policy to adults aged 19 and older (previously not covered for individuals in this age group).
Investigational criteria added
- The use of NPWT systems is considered investigational in individuals aged 11 years and younger.
Orthognathic Surgery, 9.02.501 PBC | Premera HMO
Medical necessity criteria updated
- Congenital anomalies now include Noonan syndrome and revised Pierre Robin syndrome to Pierre Robin sequence.
Investigational criteria added
- Three-dimensional virtual treatment planning or computer-aided three-dimensional simulation and navigation in orthognathic surgery is considered investigational.
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence, 1.01.17 PBC | Premera HMO
New policy
- Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary or fecal incontinence is considered investigational.
Shoulder Arthrotomy in Adults, 7.01.605 PBC | Premera HMO
Medical necessity criteria updated
- Conservative management requirements were modified to include both a medication trial with failure and a trial with failure of physical measures for the indications:
- Decompression of subacromial space or acromioplasty for rotator cuff tendonitis
- Full thickness rotator cuff repair
- Resection of distal clavicle
- Shoulder dislocation
- Synovectomy
- Additional testing now required for the following indications:
- Decompression of subacromial space or acromioplasty for rotator cuff tendonitis,
- Full thickness rotator cuff repair
- Resection of distal clavicle
- Shoulder dislocation
Medical necessity criteria removed
- Criteria for the following indications no longer included in policy:
- Acromioclavicular (AC) separation with recent traumatic event
- Shoulder pain, deformity, partial thickness rotator cuff repair
- Removal of intra-articular osteochondral lesion or loose body
- Recurrent shoulder dislocation (greater than two years, less than two years)
- Initial or recurrent shoulder dislocation with Bankart, Hill-Sachs, or anterior glenoid rim fracture
- Shoulder fracture repair
- Shoulder hardware removal
Effective August 7, 2026
Denosumab Products, 5.01.658 PBC | Premera HMO
Medical necessity criteria updated
- Bildyos (denosumab-nxxp), Enoby (denosumab-qbde), Bilprevda (denosumab-nxxp) and Xtrenbo (denosumab-qbde) now listed as preferred denosumab products.
- Boncresa, Bosaya, Conexxence, Jubbonti, Ospomyv, Osvyrti, Prolia, and Stoboclo now listed as non‑preferred products, and to require an inadequate response or intolerance to both Bildyos (denosumab‑nxxp) and Enoby (denosumab‑qbde).
- Aukelso, Bomyntra, Jubereq, Osenvelt, Oziltus, Wyost, Xbryk, and Xgeva now listed as non‑preferred products, and to require an inadequate response or intolerance to both Bilprevda (denosumab‑nxxp) and Xtrenbo (denosumab‑qbde).
- Criteria for prevention of skeletal‑related events in multiple myeloma and bone metastases from solid tumors to include a dose limit of 120 mg every 4 weeks.
Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.02.510 PBC | Premera HMO
Medical necessity criteria updated
- Now includes a requirement for implantable loop recorders (ILRs) that individuals must undergo monitoring for more the 14 consecutive days.
- Individuals may be eligible for ILRs when undergoing evaluation for suspected atrial fibrillation (AF) as a cause of cryptogenic stroke who have had a negative standard AF workup.
Effective July 2, 2026
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
Medical necessity criteria added
- Givlaari (givosiran) is subject to review for site of service administration.
Immune Checkpoint Inhibitors, 5.01.591 PBC | Premera HMO
Medical necessity criteria updated
- Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) SC is subject to review for site of service administration.
Immune Globulin Therapy, 8.01.503 PBC | Premera HMO
Medical necessity criteria added
- Yimmugo (immune globulin intravenous, human-dira) is subject to review for site of service administration.
Medical necessity criteria updated
- Guillain-Barre syndrome treatment criteria now requires severe disease with significant weakness and initiation of treatment within 4 weeks of symptom onset.
- Multifocal motor neuropathy criteria now requires stepwise or slowly progressive asymmetric limb weakness for at least 1 month, motor involvement of at least 2 nerves on nerve conduction studies, and normal sensory nerve conduction studies except
for minor vibration loss in the lower limbs.
- Neuromyelitis optica spectrum disorder criteria now allows diagnosis confirmation based on a single clinical characteristic.
- Antiphospholipid syndrome criteria now allows catastrophic antiphospholipid syndrome when plasma exchange is not an option and intravenous immunoglobulin is not used as chronic or prophylactic therapy.
Pharmacologic Treatment of High Cholesterol, 5.01.558 PBC | Premera HMO
Medical necessity criteria added
- Leqvio (inclisiran) is subject to review for site of service administration.
Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593 PBC | Premera HMO
Medical necessity criteria added
- Amvuttra (vutrisiran) and Onpattro (patisiran) are subject to review for site of service administration.
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564 PBC | Premera HMO
Medical necessity criteria added
- Rystiggo (rozanolixizumab-noli) is subject to review for site of service administration.
Medical necessity criteria updated
- Voyxact criteria revised to lower urine protein-to-creatinine ratio (UPCR) thresholds, addan estimated Glomerular Filtration Rate greater than or equal to 30 mL/min/1.73 m² requirement, exclude individuals on dialysis or post‑transplant, and require
prior inadequate response or intolerance to Filspari or Tarpeyo.
Prostate Artery Embolization, 7.01.55 PBC | Premera HMO
New policy
- Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia.
Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533 PBC | Premera HMO
Medical necessity criteria updated
- Poland syndrome added to the list of breast conditions for which reconstructive breast surgery may be considered medically necessary when criteria are met.
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523 PBC | Premera HMO
New policy
- Amvuttra (vutrisiran), Onpattro (patisiran), Yimmugo (immune globulin), Givlaari (givosiran), Keytruda Qlex (pembrolizumab and berahyaluronidase alfa‑pmph), Leqvio (inclisiran), and Rystiggo (rozanolixizumab‑noli) are subject to review for site of
service administration.
Effective July 1, 2026
Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525 PBC | Premera HMO
Title change
- Updated from Site of Service Ambulatory Service Center Select Surgical Procedures to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures in Adults.
Medical necessity criteria added
- Upper Gastrointestinal Endoscopy is subject to review for site of service.
Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533 PBC | Premera HMO
Title change
- Updated from Upper Gastrointestinal (UGI) Endoscopy for Adults to Upper Gastrointestinal (UGI) Endoscopy in Adults.
Medical necessity criteria added
- UGI endoscopy is subject to review for site of service.
Effective June 14, 2026
Effective for dates of service on and after June 14, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Genetic Testing. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Chromosomal microarray analysis
- Expanded to allow fetal testing in any individual undergoing invasive diagnostic testing
Pharmacogenetic testing
- Expanded list of drug therapies and biomarkers considered medically necessary
Whole exome sequencing and whole genome sequencing
- Added criteria for which postnatal whole genome sequencing is considered medically necessary
Liquid biopsy testing
- Added allowance for repeat testing in breast cancer with disease progression when the patient is a candidate for specific new systemic therapies aligned with Food and Drug Administration or National Comprehensive Cancer Network 2A recommendations
Liquid biopsy, Whole Exome/Whole Genome, Predictive and Prognostic Polygenic Testing, Pharmacogenetic Testing, Chromosomal Microarray Analysis
- Added statement clarifying that testing should be performed in a lab certified by CLIA and accredited by the College of American Pathologists
For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. You can also access and download a copy of the current and upcoming guidelines.
Effective June 5, 2026
Carpal Tunnel Release Surgical Treatments, 7.01.595 PBC | Premera HMO
Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525 PBC | Premera HMO
Medical necessity criteria updated
- Carpal tunnel release surgical treatments are subject to review for site of service.
Intracoronary Drug Delivery Balloon Procedures, 7.01.97 PBC | Premera HMO
New policy
- The use of percutaneous coronary intervention with a drug-coated balloon for the treatment of intracoronary in-stent restenosis is considered investigational.
Effective for dates of service on and after June 5, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Therapy. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Radiation Therapy Program Expansion
Addition of Electronic Brachytherapy – Skin and Orthovoltage
- Clinical indications:
- Treatment of non‑melanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma.
- Use in select non‑malignant conditions.
For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.